The medical letter on drugs and therapeutics february 16 2015

The Medical Letter

®

on Drugs and Therapeutics
Objective Drug Reviews Since 1959

Volume 57

ISSUE
ISSUE
No.

1433
1462

February 16, 2015

IN THIS ISSUE

Diet, Drugs, and Surgery for Weight Loss .................................................................. p 21

Volume 56

Important Copyright Message
FORWARDING OR COPYING IS A VIOLATION OF U.S. AND INTERNATIONAL COPYRIGHT LAWS

The Medical Letter, Inc. publications are protected by U.S. and international copyright laws.
Forwarding, copying or any distribution of this material is prohibited.
Sharing a password with a non-subscriber or otherwise making the contents of this site
available to third parties is strictly prohibited.

By accessing and reading the attached content I agree to comply with U.S. and international
copyright laws and these terms and conditions of The Medical Letter, Inc.

For further information click: Subscriptions, Site Licenses, Reprints
or call customer service at: 800-211-2769

Published by The Medical Letter, Inc. • A Nonprofit Organization


Revised 4/17/15: See p. 23

The Medical Letter publications are protected by US and international copyright laws.
Forwarding, copying or any other distribution of this material is strictly prohibited.
For further information call: 800-211-2769

The Medical Letter

®

on Drugs and Therapeutics
Objective Drug Reviews Since 1959

Volume 57

ISSUE

ISSUE No.

February 16, 2015
Take CME Exams

IN THIS ISSUE

1433
1462 Diet, Drugs, and Surgery for Weight Loss
Volume 56
Related article(s) since publication

Adults with a body mass index (BMI) between
25 and 29.9 kg/m2 are considered overweight. Those
with a BMI ≥30 are considered obese. Losing even
a small amount of weight and increasing physical
activity can prevent some of the complications
of obesity, particularly type 2 diabetes. Diet and
exercise are the preferred methods for losing weight,
but long-term failure rates are high. Several drugs
have been approved by the FDA for weight reduction,
but adherence is poor, adverse effects are common,
and patients usually regain the lost weight when
the drug is stopped. Bariatric surgery can produce
substantial weight loss and significantly reduce
obesity-related comorbidities; long-term data on its
safety are encouraging, but still limited. Guidelines
for the management of overweight or obese adults
have recently been published.1,2
DIET
WEIGHT LOSS — Adults can lose 1-2 lbs (0.45-0.9 kg)
per week by consuming 500-1000 fewer calories per
day. A low-calorie diet typically reduces energy intake
to 800-1500 calories daily. A very-low-calorie diet,
which reduces energy intake to <800 calories daily,

typically requires medical supervision and use of
commercially available meal replacements, increases
the risk of gallstones, and is recommended only for
short-term weight loss.
Diets that differ in macronutrient composition have
been equally effective in achieving weight loss. A
randomized 2-year trial in 811 overweight adults
compared 4 diets with the same degree of caloric
restriction, but with varying proportions of protein
(15 or 25%), fat (20 or 40%), and carbohydrate (35 to
65%); there were no significant differences in weight
loss between any of the groups.3 In another trial, diets
with various proportions of protein (15 or 25%), fat

(20 or 40%), and carbohydrate (35 to 65%) resulted in
no difference in the amount of fat mass or lean mass
lost at 6 months, nor in the location of fat mass lost
(central versus subcutaneous).4 A meta-analysis of
48 trials including 7286 overweight or obese adults
found no significant difference between a low-fat and
a low-carbohydrate diet in the amount of weight loss
achieved at 12 months (about 7-9 kg).5
MAINTENANCE — Patients on a diet generally lose 5%
of their body weight over the first 6 months, but over
2-3 years weight often returns to baseline. The
long-term ineffectiveness of weight-reduction diets
may be due not only to poor adherence, but also
to compensatory changes in energy expenditure
that oppose maintenance of a lower body weight.
Macronutrient composition may play a role in maintenance of weight loss. Data are mixed on whether a

diet high in protein reduces weight regain during the
weight maintenance phase after weight loss.6,7
A randomized, double-blind trial in 132 overweight
adults who were able to lose about 6 kg over a
12-week period found that reduced energy-density
eating strategies (eating fewer calories per volume of
food) were more effective than meal replacements or
lifestyle modification alone in reducing weight regain
over a 24-month weight maintenance period.8
LIFESTYLE INTERVENTIONS
WEIGHT LOSS — Monthly sessions with a lifestyle
coach, in addition to quarterly education visits with
a primary care provider, resulted in 1.2 kg more
weight loss over 2 years than quarterly visits alone.
Adding medication or meal replacements resulted
in an additional 2.9-kg weight loss, compared to
those who received quarterly visits alone, and 35%
of patients receiving both lifestyle counseling and
21

Published by The Medical Letter, Inc. • A Nonprofit Organization


The Medical Letter

®

either meal replacements or medication lost ≥5% of
their initial body weight.9
In another trial, in-person support counseling was

no more effective than remote support (telephone,
website, e-mail) in achieving weight loss. Both
interventions resulted in about 40% of patients
achieving weight loss of  ≥5% at 2 years.10
MAINTENANCE — Behavioral interventions focusing
on weight maintenance have had modest success. An
intense phone and mail intervention (24 phone calls
over a 2-year period and bimonthly letters starting at
month 8) to promote maintenance of weight loss was
associated with about 4 lb less regain than a minimal
approach.11 A meta-analysis of 45 trials including
7788 obese adults found that behavioral interventions
focusing on both food intake and physical activity
resulted in 1.56 kg less weight regain at 12 months
compared to controls, while taking the lipase inhibitor
orlistat (Xenical, Alli) in addition to lifestyle modification
was associated with 1.80 kg less weight regain at 12
months compared to taking placebo in addition to
lifestyle modification.12
PREVENTING DIABETES — Lifestyle modification
programs that focus on weight loss, increased
physical activity, and changes in energy intake can
reduce the risk of type 2 diabetes. A study in 3234
adults (mean age 51; mean BMI 34) with fasting
and post-load serum glucose elevations found that
lifestyle changes resulting in modest weight loss
over approximately 3 years were significantly more
effective in preventing diabetes than treatment with
metformin (Glucophage, and others); the estimated
cumulative incidence of diabetes was about 29%

with placebo, 22% with metformin, and 14% with
lifestyle changes. 13 In one follow-up study, the
reduction in the risk of developing diabetes as
a result of weight loss intervention (diet plus
exercise) was found to persist for up to 20 years. 14
IN DIABETES — A 4-year randomized trial in 5145
overweight or obese adults with type 2 diabetes
found that intensive lifestyle intervention focusing on
caloric restriction and increased physical activity was
more effective than traditional diabetes support and
education in achieving and maintaining significant
weight loss and in improving HbA1c, blood pressure,
HDL-cholesterol, and triglycerides.15 However, intensive lifestyle intervention did not reduce the incidence
of cardiovascular events, despite a 2.5% increase in
weight loss compared to controls at the end of the
study (median follow-up of 9.6 years).16
22

February 16, 2015

Vol. 57 (1462)
DRUGS

Several drugs are FDA-approved for weight loss (see
Table 1). Pharmacotherapy should be reserved for
patients with a BMI ≥30, or a BMI ≥27 with a weightrelated comorbidity such as hypertension or diabetes.
Pharmacologic treatment of obesity has been limited
by modest efficacy, adverse effects, low adherence
rates, and regain of weight with drug cessation.
SYMPATHOMIMETIC AMINES — The oldest weightloss drugs are sympathomimetic amines such as

phentermine and diethylpropion. These drugs are FDAapproved only for short-term use. Phentermine was
widely used with fenfluramine until the combination
(“phen-fen”) was found to be associated with
heart valve abnormalities.17 Fenfluramine has been
withdrawn from the market.
PHENTERMINE/TOPIRAMATE ER — Phentermine has
been approved by the FDA for use in combination
with an extended-release formulation of the antiepileptic drug topiramate as Qsymia.18 It is a schedule
IV controlled substance. Qsymia is the most effective
weight loss drug available to date, with dosedependent weight loss of 6-13 kg over 56 weeks; 70%
of patients treated with the higher dose of the drug
achieved ≥5% weight loss.19,20 A 2-year continuation
study found that phentermine/topiramate ER was
effective in maintaining weight loss over 2 years, with
little weight regression back to baseline weight.21 A
titration protocol is recommended. If ≥5% weight loss
is not achieved after 12 weeks on the maximum dose,
the drug should gradually be discontinued; abrupt
discontinuation of topiramate can cause seizures,
even in patients with no history of epilepsy.
Adverse effects include dry mouth, paresthesia,
constipation, dysgeusia, and, with higher doses,
insomnia. Discontinuation rates for varying doses
of phentermine/topiramate ER have ranged from
30-40%. Cognition, attention, concentration, and
memory disturbances have been reported. Increases
in heart rate have been observed in clinical trials; until
cardiovascular safety data become available, this
combination is not recommended for patients with
underlying cardiovascular disease. Qsymia should

not be used within 14 days of an MAO inhibitor.
Topiramate is a carbonic anhydrase inhibitor and
can cause metabolic acidosis, increasing the risk of
renal stones. Qsymia is contraindicated for use during
pregnancy and is only available through a restricted
access program designed to prevent fetal exposure to
the drug.


Revised 4/17/15: In Table 1, the mean weight loss range for lorcaserin has been revised (please see addendum) and a new footnote,
number 19, has been added.

The Medical Letter

Vol. 57 (1462)

®

February 16, 2015

Table 1. Some FDA-Approved Drugs for Treatment of Obesity1
Drug

Mean Weight Loss2/
% Patients with
Weight Loss ≥5%

Cost3

See Footnote 4

See Footnote 4
See Footnote 4

$23.50
85.50
20.10

15-37.5 mg once/d

See Footnote 4
See Footnote 4
See Footnote 4

8.30
50.90
17.10

37.5 mg once/d
15-37.5 mg once/d

See Footnote 4
See Footnote 4

63.00
110.80

7.5/46, 15/92 mg
ER caps5

7.5/46-15/92 mg

once/d

4.1-10.7 kg/45-70%6,7,19

120 mg caps
60 mg caps

120 mg tid
60 mg tid

2.5-3.4 kg/35-73%8

469.80
44.00

10 mg tabs

10 mg bid

2.9-3.6 kg/38-48%10-12

199.50

8/90 mg ER tabs

16/180 mg bid

3.7-5.2 kg/39-66%13-15,19

199.50

18 mg/3 mL prefilled pen16

3 mg SC once/d

3.7-5.8 kg/44-62%17,18,19

N.A.

Some Available
Formulations

Usual
Adult Dosage

50 mg tabs

25-50 mg once/d-tid

25 mg tabs;
75 mg ER tabs
35 mg tabs

25 mg tid or
75 mg once/d
35 mg bid or tid

15, 30, 37.5 mg caps;
37.5 mg tabs
37.5 mg tabs, caps

15, 30, 37.5 mg ODT

Sympathomimetic Amines
Benzphetamine – generic
Didrex (Pfizer)
Diethylpropion – generic
Phendimetrazine – generic
Bontril PDM (Valeant)
Phentermine – generic
Adipex-P (Teva)
Suprenza (Akrimax)

Sympathomimetic Amine/Antiepileptic Combination
Phentermine/topiramate ER –
Qsymia (Vivus)

170.70

Lipase Inhibitor
Orlistat – Xenical (Genentech)
Alli9 (GSK)
Serotonin Receptor Agonist
Lorcaserin – Belviq (Eisai)

Antidepressant/Opioid Antagonist Combination
Bupropion/naltrexone –
Contrave (Orexigen/Takeda)
GLP-1 Agonist
Liraglutide –
Saxenda (Novo Nordisk)

ER = extended-release; ODT = orally disintegrating tablets.
N.A. = Product will be available first half of 2015. Cost not yet available.
1. Weight loss drugs, including over-the-counter medications, are not recommended for use during pregnancy.
2. Weight loss above diet and lifestyle modifications alone. Placebo-corrected weight loss.
3. Approximate WAC for 30 days’ treatment with the lowest strength available. WAC = wholesaler acquisition cost or manufacturer’s published price to
wholesalers; WAC represents a published catalogue or list price and may not represent an actual transactional price. Source: AnalySource® Monthly.
February 5, 2015. Reprinted with permission by First Databank, Inc. All rights reserved. ©2015. www.fdbhealth.com/policies/drug-pricing-policy. Medicare
does not cover obesity drugs.
4. Only approved for short-term use (a few weeks). Most studies have reported an additional weight loss of a fraction of a pound per week compared to
placebo-treated patients.
5. Also available in 3.75/23 mg and 11.25/69 mg capsules which are intended for use only during titration.
6. DB Allison et al. Obesity (Silver Spring) 2012; 20:330.
7. KM Gadde et al. Lancet 2011; 377:1341.
8. SZ Yanovski and JA Yanovksi. JAMA 2014; 311:74.
9. Available over the counter.
10. SR Smith et al. N Engl J Med 2010; 363:245.
11. MC Fidler et al. J Clin Endocrinol Metab 2011; 96:3067.
12. PM O’Neil et al. Obesity (Silver Spring) 2012; 20:1426.
13. FL Greenway et al. Lancet 2010; 376:595.
14. CM Apovian et al. Obesity (Silver Spring) 2013; 21:935.
15. A Wadden et al. Obesity (Silver Spring) 2011; 19:110.
16. Each pen can deliver doses of 0.6, 1.2, 1.8, 2.4, or 3 mg. Sold in packages containing 3 or 5 multi-dose pens.
17. A Astrup et al. Int J Obesity (Lond) 2012; 36:843.
18. TA Wadden et al. Int J Obesity (Lond) 2015; 39:187.
19. The range includes weight loss observed with titration and maintenance dosages.

ORLISTAT — Available both over the counter (Alli) and
by prescription (Xenical), orlistat is a pancreatic and
gastric lipase inhibitor that decreases absorption of

fat from the gastrointestinal tract. Used as an adjunct
to diet, it is modestly effective in increasing weight
loss. Patients taking orlistat 120 mg three times daily
for 1-4 years have lost about 3 kg more than those
taking placebo.22 A meta-analysis of 8 trials in a total
of 1738 subjects found that use of orlistat to maintain
weight loss was associated with 1.8 kg less weight
regain compared to placebo over a 12-month period,

with a dose-dependent effect (-2.3 kg with 120 mg;
-0.7 kg with 30 and 60 mg).12
Adverse effects, including flatulence with discharge,
oily spotting, and fecal urgency, occur predominantly
after high-fat dietary indiscretions and are associated
with a high incidence of drug discontinuation. Severe
liver injury has been reported rarely in patients taking
orlistat; a cause-and-effect relationship has not been
established. An increase in oxalate absorption with
orlistat may increase the development of calcium
23


The Medical Letter

®

oxalate renal stones. Fat-soluble vitamin supplements
should be taken 2 hours before or after taking orlistat.
Levothyroxine should be taken 4 hours before or after
taking orlistat. Orlistat is contraindicated for use

during pregnancy.
LORCASERIN — Lorcaserin (Belviq) is a selective
serotonin 2C agonist that suppresses appetite. A
schedule IV controlled substance, it is only modestly
effective for weight loss, but is generally well tolerated. In all studies, <50% of adults taking the drug lost
≥5% of their initial body weight; the average placebocorrected weight loss after one year of use has been
about 3 kg.18 Patients who continued on lorcaserin
regained about 25% of their initial weight loss in the
second year, while those who stopped the drug after
one year lost an average of only 1.2 kg more at 2
years than those who had taken placebo for 2 years.23
Patients who do not lose ≥5% of their baseline weight
by 12 weeks should stop taking lorcaserin.
Adverse effects of lorcaserin have included headache, nausea, and dizziness. Episodes of euphoria
and impairment of attention and cognition have been
reported. As with other weight loss medications,
drug discontinuation rates in the clinical trials have
been in the range of 35-50%. The labeling includes a
warning about the possibility of cardiac valvulopathy
(it did not occur significantly more frequently
with lorcaserin than with placebo in clinical trials)
because agonism of the 2B serotonin receptor was
implicated in the cardiac valvulopathy associated
with fenfluramine. Serotonin syndrome has been
reported; lorcaserin is not recommended for use
with other serotonergic or antidopaminergic drugs,
such as selective serotonin reuptake inhibitors
(SSRIs), serotonin and norepinephrine reuptake
inhibitors (SNRIs), or monoamine oxidase inhibitors
(MAOIs). Lorcaserin is contraindicated for use during

pregnancy.
BUPROPION/NALTREXONE — A fixed-dose combination (Contrave) of the antidepressant and smoking
cessation drug bupropion (Wellbutrin SR, Zyban, and
others) and the opioid receptor antagonist naltrexone
(ReVia, and others) has been approved for weight loss.
Unlike phentermine/topiramate ER and lorcaserin,
bupropion/naltrexone is not a controlled substance.
Bupropion is an appetite suppressant, while naltrexone
potentiates that effect. In four clinical trials, bupropion/
naltrexone was associated with ≥5% weight loss in
39-66% of patients after 56 weeks. Placebo-corrected
weight loss at the end of 56 weeks was 4-5 kg in the 3
24

Vol. 57 (1462)

February 16, 2015

largest trials.24 A titration protocol is recommended; if
weight loss of ≥5% is not achieved after 12 weeks on
the maintenance dosage, the drug should gradually be
discontinued.
Adverse effects of bupropion/naltrexone have
included nausea (the major reason for discontinuation), vomiting, headache, constipation, dizziness,
and dry mouth. The package insert includes a boxed
warning about suicidal thoughts and behavior
associated with use of antidepressants and serious
neuropsychiatric reactions reported with use of
bupropion for smoking cessation; clinical trials of
bupropion/naltrexone did not find an association with

suicidality. Bupropion may lower the seizure threshold
and can cause CNS depression; additive effects
could occur when bupropion is used concomitantly
with other drugs that increase seizure risk or cause
CNS depression. Aminotransferase elevations and
hepatotoxicity have been reported in patients taking naltrexone. Contrave is contraindicated for use
during pregnancy.
LIRAGLUTIDE — The injectable glucagon-like
peptide-1 (GLP-1) agonist liraglutide, FDA-approved
for treatment of type 2 diabetes as Victoza,25 has
recently been approved for weight loss as Saxenda. A
randomized, double-blind trial in obese adults without
diabetes found that after one year patients treated with
liraglutide 3 mg/day (maximum dosage for diabetes is
1.8 mg daily) lost 5.8 kg more than patients treated
with placebo and 3.8 kg more than those treated with
orlistat.26 Liraglutide 3 mg/day was more effective than
placebo in maintaining a ≥5% weight loss achieved
by a low-calorie diet in overweight or obese adults
without diabetes (422 participants), and induced an
additional weight loss (5.9 kg more than with placebo)
over a 56-week period.27
Adverse effects of liraglutide have included nausea,
vomiting, constipation, and diarrhea. Liraglutide
slows gastric emptying and may decrease the rate
and extent of absorption of other drugs. Thyroid
C-cell hyperplasia has been reported with use of
liraglutide in rats, and the FDA has required a boxed
warning about the risk of thyroid C-cell tumors in the
package insert. Saxenda is contraindicated for use

during pregnancy.
IN DIABETES — A meta-analysis of 7 trials in a total of
2550 overweight or obese adults with type 2 diabetes
found an additional 0.4% reduction in HbA1c with
orlistat for 6 or 12 months compared to placebo.28
A 56-week randomized, double-blind trial in 130


The Medical Letter

®

overweight or obese patients with type 2 diabetes
found that phentermine/topiramate ER produced an
additional 6.7% weight loss and 0.4% reduction in
HbA1c compared to placebo.29 A controlled trial in
604 overweight or obese adults with type 2 diabetes
on metformin, a sulfonylurea, or both showed a
placebo-corrected decrease in HbA1c of 0.5-0.6%
with lorcaserin.30 In a 56-week double-blind trial in
505 overweight or obese adults with type 2 diabetes,
bupropion/naltrexone produced an additional 3.2%
weight loss and 0.5% reduction in HbA1c compared
to placebo.31
Weight loss increases insulin sensitivity and may
increase the risk of hypoglycemia in patients with
diabetes taking glucose-lowering medications.
OFF-LABEL — Several types of medications not
approved by the FDA for treatment of obesity have
shown benefit in achieving weight loss.

Antidepressants – Serotonin is believed to play a role
in regulation of satiety. Patients who take selective
serotonin reuptake inhibitors (SSRIs) for depression
may lose weight in the short term, but long-term use
of SSRIs can lead to weight gain, with some patients
becoming heavier than they were at baseline. They are
not recommended for weight loss.
Antiepileptics — A one-year randomized, doubleblind trial of zonisamide (Zonegran, and generics)32
in 225 patients with a mean BMI of 38 found that a
400-mg daily dose caused 3.3 kg more weight loss
than placebo.33 A study in 42 patients with bipolar
disorder or schizophrenia starting the antipsychotic
olanzapine (Zyprexa, and others) found that adding
zonisamide (mean dose ~400 mg) was effective in
preventing weight gain (about 4 kg less weight gain
than with placebo), but at the expense of cognitionrelated adverse events.34
Zonisamide can cause constipation, diarrhea, impaired
attention, cognition and memory, and anxiety- and
depression-related adverse effects. It is a carbonic
anhydrase inhibitor and can cause metabolic acidosis,
increasing the risk of renal stones. Rash, including
fatal Stevens-Johnson syndrome and toxic epidermal
necrolysis, has been reported.
Antihyperglycemics — Metformin (Glucophage, and
others), a biguanide marketed for oral treatment of type
2 diabetes, has produced modest weight loss in some
patients, including some who have impaired glucose
metabolism (“pre-diabetes”) or who take antipsychotic
medications that cause weight gain. A long-term

Vol. 57 (1462)

February 16, 2015

follow-up study of 3234 overweight patients with
impaired glucose metabolism found that adherence to
metformin predicted sustained weight loss, with highly
adherent patients averaging 3.1 kg of weight loss and
all metformin patients averaging 1.9 kg of weight loss
throughout the 9-year follow-up period.35
Metformin can cause unpleasant gastrointestinal
effects, including metallic taste, nausea, diarrhea,
and abdominal pain; some of these may resolve with
continued use.
Exenatide (Bydureon, Byetta), an injectable GLP-1
agonist that stimulates glucose-dependent insulin
secretion, is FDA-approved as an adjunct to oral
agents for treatment of type 2 diabetes.36 In 152 obese
adults with impaired glucose metabolism, exenatide
for 24 weeks in conjunction with lifestyle modification
produced a 5.1-kg weight loss compared to a 1.6-kg
loss with placebo.37
Adverse effects of exenatide include nausea, vomiting,
diarrhea, and injection site pruritus. Thyroid C-cell
hyperplasia has been reported with use of exenatide
in rats, and the FDA has required a boxed warning
about the risk of thyroid C-cell tumors in the package
insert. Pancreatitis and renal insufficiency have been
reported.38 Exenatide slows gastric emptying and
may decrease the rate and extent of absorption of

oral drugs.
Pramlintide (Symlin), an amylin analog given by
subcutaneous injection before meals at the same
time as insulin, can produce weight loss.39 Pramlintide
120 mcg 3 times daily, or 240 mcg or 360 mcg 2 or
3 times daily, was more effective than placebo in
preventing weight regain after an initial 4-month
weight-loss trial in 411 obese patients without
diabetes. Weight loss at month 12 was 6-8 kg with
pramlintide, while patients on placebo regained all
the weight they had lost.40
Adverse effects have included nausea, irritation at
the injection site, and mild hypoglycemia. Pramlintide
slows gastric emptying and may decrease the rate
and extent of absorption of oral drugs.
Canagliflozin (Invokana), dapagliflozin (Farxiga), and
empagliflozin (Jardiance), oral sodium glucose cotransporter 2 (SGLT-2) inhibitors approved only for
treatment of diabetes, have produced weight loss
of 2-4 kg. Mycotic infections in both women and
men and a possible increase in bladder cancer with
dapagliflozin have limited their use.41-43

25


The Medical Letter

®

BARIATRIC SURGERY

Surgical treatment for obesity is generally limited
to patients with a BMI ≥40, or a BMI ≥35 with an
obesity-related comorbidity. Procedures that cause
malabsorption (Roux-en-Y gastric bypass) are
associated with greater weight loss and more adverse
effects than purely restrictive procedures such as
adjustable gastric banding and sleeve gastrectomy.
ADJUSTABLE GASTRIC BANDING — Use of an
adjustable gastric band placed laparoscopically
around the proximal portion of the stomach and
injected with variable amounts of saline has largely
replaced fixed gastric banding. If patients continue
to feel hungry or are not losing weight at an expected
rate, they can receive an outpatient injection of saline
through a subcutaneous reservoir to help increase
restriction and promote satiety.
Efficacy – A prospective cohort study in 3227 patients,
most followed for ≥10 years, found a loss of excess
weight (“excess weight” is the weight in kilograms
above the weight at a BMI of 25) of 47% with the
laparoscopic adjustable gastric band.44
Adverse Effects – Adjustable gastric banding is
a restrictive procedure with no associated malabsorption. There was no perioperative mortality with
placement of a laparoscopic adjustable gastric band
in the prospective cohort study in >3000 patients
followed for  ≥10 years. Slippage, band erosion, excess
vomiting, and port site and tubing problems are the
most common adverse effects; these may require an
operative revision.
SLEEVE GASTRECTOMY — Sleeve gastrectomy is a

laparoscopic partial gastrectomy, in which most of the
greater curvature of the stomach is removed resulting
in a tubular stomach. It is now a primary procedure
for patients with a higher BMI who might not achieve
weight loss goals with bypass or banding.
Efficacy – A meta-analysis of 12 studies (377 patients)
of laparoscopic sleeve gastrectomy with follow-ups of
≥5 years found a mean excess weight loss of 59%.45
Adverse Effects – Since sleeve gastrectomy is a
restrictive procedure, it does not cause malabsorption.
It has a shorter operative time than gastric bypass and
a lower rate of reoperation.
ROUX-EN-Y GASTRIC BYPASS — A mixed restrictive
and malabsorptive procedure, Roux-en-Y gastric
bypass creates a proximal 20-30 mL pouch of stomach
and anastomoses it to a limb of jejunum, bypassing
26

Vol. 57 (1462)

February 16, 2015

most of the stomach, all of the duodenum, and the first
15-20 cm of the jejunum. Undigested nutrients meet
digestive enzymes in the common channel where the
two separated limbs join.
Efficacy – A meta-analysis of 29 studies including
7971 patients with at least a 2-year follow-up reported
66% excess weight loss in patients undergoing
gastric bypass.46

Adverse Effects – In a prospective, non-randomized
study of 30-day outcomes, perioperative mortality
for Roux-en-Y gastric bypass surgery was 0.2%
(n=2975) when performed laparoscopically, and 2.1%
(n=437) with an open procedure. The composite endpoint of death, deep vein thrombosis (DVT) or venous
thromboembolism (VTE), reintervention, or hospital stay
over 30 days occurred more commonly with open than
with laparoscopic procedures (7.8% vs. 4.8%).47 Iron,
calcium, folate, vitamin D, and vitamin B12 deficiencies
can occur because of malabsorption. Dumping
syndrome (nausea, bloating, colic, diarrhea) can occur
because of rapid emptying from the gastric pouch into
the jejunum. Some patients who had a gastric bypass
developed clinically significant hyperinsulinemic
hypoglycemia; the mechanism is unclear.48
BILIOPANCREATIC DIVERSION — Biliopancreatic
diversion with duodenal switch (BPD/DS) combines
a restrictive procedure similar to sleeve gastrectomy
with a bypass procedure that bypasses about three
quarters of the small intestine. It results in greater
weight loss (≥70% excess weight loss) than adjustable
gastric banding, sleeve gastrectomy, or Roux-en-Y
gastric bypass, but with higher risks of complications
and death.
MAESTRO RECHARGEABLE SYSTEM — The Maestro
Rechargeable System has recently been approved
by the FDA for adults who have not been able to lose
weight with a weight loss program within the past 5
years and who have a BMI ≥40, or a BMI ≥35 and at
least one obesity-related comorbidity. The system,

which consists of a rechargeable pulse generator, wire
leads, and electrodes that are surgically implanted into
the abdomen, delivers intermittent electrical pulses
to the trunks in the abdominal vagus nerve. It will be
reviewed in a future issue.
SURGICAL COMPARISONS — In one meta-analysis,
sleeve gastrectomy and gastric bypass resulted in
more weight loss than gastric banding (one-year
excess weight loss ~70% vs. ~33%), but gastric
banding was safer with lower mortality rates than


The Medical Letter

®

either gastric bypass or sleeve gastrectomy.49 A
meta-analysis of comorbidity resolution found
remission rates of 67% for type 2 diabetes, 38% for
hypertension, and 60% for dyslipidemia with gastric
bypass, compared to remission rates of 29% for
type 2 diabetes, 17% for hypertension, and 23% for
dyslipidemia with gastric banding studies.46 Sleeve
gastrectomy is less effective than gastric bypass, but
it has a lower incidence of procedural complications.50
IN DIABETES — A prospective trial in 60 patients with
type 2 diabetes and mean BMI of 45 found that 75% of
patients who received a gastric bypass had complete
remission of their diabetes, compared to none of those
receiving conventional medical therapy.51

A one-year trial found that among 150 patients with
type 2 diabetes and a mean BMI of 36, gastric bypass
and sleeve gastrectomy were associated with weight
loss of 29 kg and 25 kg and diabetes remission rates
of 42% and 37%, respectively, compared to weight
loss of 5.4 kg and remission rates of 12% for those
who received intensive medical therapy.52 Longerterm 3-year data from this cohort found durable
surgical weight loss rates of 21-25% compared to
baseline and persistent diabetes remission rates
(HbA1c <6%) of 38% for gastric bypass and 24% for
sleeve gastrectomy, both above the levels achieved by
medical therapy alone.53
Compared to usual care, bariatric surgery was
associated with increased remission from diabetes
and a lower incidence of micro- and macrovascular
complications.54 In one study, the factors that predicted
diabetes remission were BMI ≤50, diabetes duration ≤4
years, HbA1c ≤7.1%, and absence of insulin therapy.55
CARDIOVASCULAR DISEASE AND MORTALITY — In
a 10-year prospective, non-randomized trial in 4047
obese adults, maximal weight loss (32% with gastric
bypass and 20% with gastric banding) occurred
after 1-2 years among the 2010 patients who had
surgery. Mortality (adjusted for sex, age, and risk
factors) was 29% lower in patients who had surgery
compared to those who received conventional
treatment. Bariatric surgery was also associated
with a reduced number of cardiovascular deaths
(HR 0.47) and a reduced incidence of cardiovascular
events (HR 0.67).56 A meta-analysis of 44,022

patients from 8 clinical trials of gastric bypass or
adjustable gastric banding found reductions in
all-cause mortality (OR 0.70) and cardiovascular
mortality (OR 0.58) in surgically treated patients
compared to obese controls.57 ■

Vol. 57 (1462)

February 16, 2015

1. CM Apovian et al. Pharmacological management of obesity: an
Endocrine Society Clinical Practice Guideline. J Clin Endocrinol
Metab 2015 January 15 (epub).
2. MD Jensen et al. 2013 AHA/ACC/TOS guideline for the
management of overweight and obesity in adults: a report
of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and The
Obesity Society. J Am Coll Cardiol 2014; 63:2985.
3. FM Sacks et al. Comparison of weight-loss diet with different
compositions of fat, protein, and carbohydrates. N Engl J Med
2009; 360:859.
4. RJ de Souza et al. Effects of 4 weight-loss diets differing in
fat, protein, and carbohydrate on fat mass, lean mass, visceral
adipose tissue, and hepatic fat: results from the POUNDS LOST
trial. Am J Clin Nutr 2012; 95:614.
5. BC Johnston et al. Comparison of weight loss among named
diet programs in overweight and obese adults: a meta-analysis.
JAMA 2014; 312:923.
6. EA Delbridge et al. One-year weight maintenance after
significant weight loss in healthy overweight and obese

subjects: does diet composition matter? Am J Clin Nutr 2009;
90:1203.
7. TM Larsen et al. Diets with high or low protein content and
glycemic index for weight-loss maintenance. N Engl J Med
2010; 363:2102.
8. MR Lowe et al. Meal replacements, reduced energy density
eating, and weight loss maintenance in primary care patients: a
randomized controlled trial. Obesity (Silver Spring) 2014; 22:94.
9. TA Wadden et al. A two-year randomized trial of obesity
treatment in primary care practice. N Engl J Med 2011;
365:1969.
10. LJ Appel et al. Comparative effectiveness of weight-loss
interventions in clinical practice. N Engl J Med 2011; 365:1959.
11. NE Sherwood et al. Enhancing long-term weight loss
maintenance: 2 year results from the Keep It Off randomized
controlled trial. Prev Med 2013; 56:171.
12. SU Dombrowski et al. Long term maintenance of weight loss
with non-surgical interventions in obese adults: systematic
review and meta-analyses of randomised controlled trials.
BMJ 2014; 348:g2646.
13. WC Knowler et al. Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med 2002;
346:393.
14. G Li et al. The long-term effect of lifestyle interventions to
prevent diabetes in the China Da Qing Diabetes Prevention
Study: a 20-year follow-up study. Lancet 2008; 371:1783.
15. Look AHEAD Research Group. Long-term effects of a lifestyle
intervention on weight and cardiovascular risk factors in
individuals with type 2 diabetes mellitus: four-year results of
the Look AHEAD trial. Arch Intern Med 2010; 170:1566.

16. Look AHEAD Research Group. Cardiovascular effects of
intensive lifestyle intervention in type 2 diabetes. N Engl J Med
2013; 369:145.
17. H Jick. Heart valve disorders and appetite-suppressant drugs.
JAMA 2000; 283:1738.
18. Two drugs for weight loss. Med Lett Drugs Ther 2012; 54:69.
19. DB Allison et al. Controlled-release phentermine/topiramate in
severely obese adults: a randomized controlled trial (EQUIP).
Obesity 2012; 20:330.
20. KM Gadde et al. Effects of low-dose, controlled-release,
phentermine plus topiramate combination on weight and
associated comorbidities in overweight and obese adults
(CONQUER): a randomised, placebo-controlled, phase 3 trial.
Lancet 2011; 377:1341.
21. WT Garvey et al. Two-year sustained weight loss and metabolic
benefits with controlled-release phentermine/topiramate

27


The Medical Letter

®

in obese and overweight adults (SEQUEL): a randomized,
placebo-controlled, phase 3 extension study. Am J Clin Nutr
2012; 95:297.
22. SZ Yanovski and JA Yanovski. Long-term drug treatment for
obesity: a systematic and clinical review. JAMA 2014; 311:74.
23. SR Smith et al. Multicenter, placebo-controlled trial of lorcaserin

for weight management. N Engl J Med 2010; 363:245.
24. Contrave – A combination of bupropion and naltrexone for
Weight Loss. Med Lett Drugs Ther 2014; 56:112.
25. Liraglutide (Victoza) for type 2 diabetes. Med Lett Drugs Ther
2010; 52:25.
26. A Astrup et al. Safety, tolerability and sustained weight loss over
2 years with the once-daily human GLP-1 analog, liraglutide. Int
J Obes (Lond) 2012; 36:843.
27. TA Wadden et al. Weight maintenance and additional weight
loss with liraglutide after low-calorie-diet-induced weight loss:
the SCALE Maintenance randomized study. Int J Obes (Lond)
2013; 37:1443.
28. S Jacob et al. Orlistat 120 mg improves glycaemic control in
type 2 diabetic patients with or without concurrent weight loss.
Diabetes Obes Metab. 2009; 11:361.
29. WT Garvey et al. Weight-loss therapy in type 2 diabetes: effects
of phentermine and topiramate extended release. Diabetes
Care 2014; 37:3309.
30. PM O’Neil et al. Randomized placebo-controlled clinical trial
of lorcaserin for weight loss in type 2 diabetes mellitus: the
BLOOM-DM study. Obesity (Silver Spring) 2012; 20:1426.
31. P Hollander et al. Effects of naltrexone sustained-release/
bupropion sustained-release combination therapy on body
weight and glycemic parameters in overweight and obese
patients with type 2 diabetes. Diabetes Care 2013; 36:4022.
32. Zonisamide (Zonegran) for epilepsy. Med Lett Drugs Ther 2000;
42:94.
33. KM Gadde et al. Zonisamide for weight reduction in obese
adults: a 1-year randomized controlled trial. Arch Intern Med
2012;172:1557.

34. SL McElroy et al. A randomized, placebo-controlled study of
zonisamide to prevent olanzapine-associated weight gain. J
Clin Psychopharmacol 2012; 32:165.
35. Diabetes Prevention Program Research Group. Long-term
safety, tolerability, and weight loss associated with metformin
in the Diabetes Prevention Program Outcomes Study. Diabetes
Care 2012; 35:731.
36. Drugs for type 2 diabetes. Treat Guidel Med Lett 2014; 12:17.
37. J Rosenstock et al. Effects of exenatide and lifestyle
modification on body weight and glucose tolerance in obese
subjects with and without pre-diabetes. Diabetes Care 2010;
33:1173.
38. In brief: exenatide (Byetta) for weight loss. Med Lett Drugs Ther
2006; 48:21.
39. Pramlintide (Symlin) for diabetes. Med Lett Drugs Ther 2005;
47:43.
40. SR Smith et al. Sustained weight loss following 12-month
pramlintide treatment as an adjunct to lifestyle intervention in
obesity. Diabetes Care 2008; 31:1816.
41. Canagliflozin (Invokana) for type 2 diabetes. Med Lett Drugs
Ther 2013; 55:37.
42. Dapagliflozin (Farxiga) for type 2 diabetes. Med Lett Drugs Ther
2014; 56:13.
43. Empagliflozin (Jardiance) for type 2 diabetes. Med Lett Drugs
Ther 2014; 56:99.
44. PE O’Brien et al. Long-term outcomes after bariatric surgery:
fifteen-year follow-up of adjustable gastric banding and a
systematic review of the bariatric surgical literature. Ann Surg
2013; 257:87.
45. T Diamantis et al. Review of long-term weight loss results after

28

Vol. 57 (1462)

February 16, 2015

laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;
10:177.
46. N Puzziferri et al. Long-term follow-up after bariatric surgery: a
systematic review. JAMA 2014; 312:934.
47. Longitudinal Assessment of Bariatric Surgery (LABS)
Consortium. Perioperative safety in the longitudinal assessment
of bariatric surgery. N Engl J Med 2009; 361:445.
48. GJ Service et al. Hyperinsulinemic hypoglycemia with
nesidioblastosis after gastric-bypass surgery. N Engl J Med
2005; 353:249.
49. SH Chang et al. The effectiveness and risks of bariatric surgery:
an updated systematic review and meta-analysis, 2003 – 2012.
JAMA Surg 2014; 149:275
50. Ottawa (ON): Canadian Agency for Drugs and Technologies in
Health 2014 April 24. Bariatric surgical procedures for obese
and morbidly obese patients: a review of comparative clinical
and cost effectiveness, and guidelines. Available at: www.ncbi.
nlm.nih.gov/pubmedhealth/PMH00715681. Accessed February 5, 2015.
51. G Mingrone et al. Bariatric surgery versus conventional medical
therapy for type 2 diabetes. N Engl J Med 2012; 366:1577.
52. PR Schauer et al. Bariatric surgery versus intensive medical
therapy in obese patients with diabetes. N Engl J Med 2012;
366:1567.

53. PR Schauer et al. Bariatric surgery versus intensive medical
therapy for diabetes – 3 year outcomes. N Engl J Med 2014;
370:2002.
54. L Sjöström et al. Association of bariatric surgery with longterm remission of type 2 diabetes and with microvascular and
macrovascular complications. JAMA 2014; 311:2297.
55. M Robert et al. Predictive factors of type 2 diabetes remission 1
year after bariatric surgery: impact of surgical techniques. Obes
Surg 2013: 23:770.
56. L Sjöström et al. Bariatric surgery and long-term cardiovascular
events. JAMA 2012; 307:56.
57. AE Pontiroli et al. Long-term prevention of mortality in morbid
obesity through bariatric surgery. a systematic review and
meta-analysis of trials performed with gastric banding and
gastric bypass. Ann Surg 2011; 253:484.

Coming Soon in The Medical Letter:
Inhaled Insulin (Afrezza)
Ceftolozane/tazobactam (Zerbaxa) – A New Cephalosporin
and Beta-lactamase Inhibitor Combination
Suvorexant (Belsomra) for Insomnia
Drugs for Treatment of ADHD

Read Our Blog: More@MedLetter
Each week or two we publish a short blog post commenting
on topics previously or about to be published in The Medical
Letter. Visit blog.medicalletter.org and share your thoughts
with us.


The Medical Letter publications are protected by US and international copyright laws.

Forwarding, copying or any other distribution of this material is strictly prohibited.
For further information call: 800-211-2769

The Medical Letter

®

on Drugs and Therapeutics
Objective Drug Reviews Since 1959
Volume 57 (Issue 1467)

April 27, 2015

Addendum: Diet, Drugs, and Surgery for Weight Loss
In the article on Diet, Drugs, and Surgery for Weight
Loss in the February 16, 2015 issue of The Medical
Letter (volume 57), the mean weight loss listed in table 1
included, at the lower end of the range, the mean weight
loss reported with a lower than FDA-approved dose of
lorcaserin (Belviq). The placebo-corrected weight loss
reported with FDA-approved doses of lorcaserin is 2.93.6 kg. This change has been made in the article as it
appears online.

EDITOR IN CHIEF: Mark Abramowicz, M.D.; EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical School; EDITOR: Jean-Marie Pflomm, Pharm.D.;
ASSISTANT EDITORS, DRUG INFORMATION: Susan M. Daron, Pharm.D., Corinne Z. Morrison, Pharm.D., Michael P. Viscusi, Pharm.D.; CONSULTING EDITORS: Brinda M. Shah, Pharm.D.,
F. Peter Swanson, M.D; SENIOR ASSOCIATE EDITOR: Amy Faucard
CONTRIBUTING EDITORS: Carl W. Bazil, M.D., Ph.D., Columbia University College of Physicians and Surgeons; Vanessa K. Dalton, M.D., M.P.H., University of Michigan Medical
School; Eric J. Epstein, M.D., Albert Einstein College of Medicine; Jane P. Gagliardi, M.D., M.H.S., F.A.C.P., Duke University School of Medicine; Jules Hirsch, M.D., Rockefeller
University; David N. Juurlink, BPhm, M.D., Ph.D., Sunnybrook Health Sciences Centre; Richard B. Kim, M.D., University of Western Ontario; Hans Meinertz, M.D., University Hospital,
Copenhagen; Sandip K. Mukherjee, M.D., F.A.C.C., Yale School of Medicine; Dan M. Roden, M.D., Vanderbilt University School of Medicine; Esperance A.K. Schaefer, M.D., M.P.H.,

Harvard Medical School; F. Estelle R. Simons, M.D., University of Manitoba; Neal H. Steigbigel, M.D., New York University School of Medicine; Arthur M. F. Yee, M.D., Ph.D., F.A.C.R.,
Weill Medical College of Cornell University
MANAGING EDITOR: Susie Wong; ASSISTANT MANAGING EDITOR: Liz Donohue; EDITORIAL ASSISTANT: Cheryl Brown
EXECUTIVE DIRECTOR OF SALES: Gene Carbona; FULFILLMENT & SYSTEMS MANAGER: Cristine Romatowski; DIRECTOR OF MARKETING COMMUNICATIONS: Joanne F. Valentino;
VICE PRESIDENT AND PUBLISHER: Yosef Wissner-Levy
Founded in 1959 by
Arthur Kallet and Harold Aaron, M.D.
Copyright and Disclaimer: The Medical Letter, Inc. is an independent nonprofit organization that provides healthcare professionals with unbiased drug prescribing recommendations. The editorial
process used for its publications relies on a review of published and unpublished literature, with an emphasis on controlled clinical trials, and on the opinions of its consultants. The Medical Letter,
Inc. is supported solely by subscription fees and accepts no advertising, grants, or donations. No part of the material may be reproduced or transmitted by any process in whole or in part without
prior permission in writing. The editors do not warrant that all the material in this publication is accurate and complete in every respect. The editors shall not be held responsible for any damage
resulting from any error, inaccuracy, or omission.

Subscription Services
Address:
The Medical Letter, Inc.
145 Huguenot St. Ste. 312
New Rochelle, NY 10801-7537
www.medicalletter.org

Customer Service:
Call: 800-211-2769 or 914-235-0500
Fax: 914-632-1733
E-mail:

Permissions:
To reproduce any portion of this issue,
please e-mail your request to:

Subscriptions (US):
1 year - $98; 2 years - $189;
3 years - $279. $49 per year
for students, interns, residents, and
fellows in the US and Canada.
Reprints - $12 each.

Copyright 2015. ISSN 1523-2859

66

Published by The Medical Letter, Inc. • A Nonprofit Organization

Site License Inquiries:
E-mail:
Call: 800-211-2769 ext. 315
Special rates available for bulk
subscriptions.


The Medical Letter

®

Continuing Medical Education Program
medicalletter.org/cme
Earn Up To 52 Credits Per Year
Choose CME from The Medical Letter in the format that’s right for you!
▶ Comprehensive Exam – Available online or in print to Medical Letter subscribers, this 78 question test enables you to earn 13 credits immediately
upon successful completion of the test. A score of 70% or greater is required to pass the exam. Our comprehensive exams allow you to test at your

own pace in the comfort of your home or office. Comprehensive tests are offered every January and July enabling you to earn up to 26 credits per
year. Starting with our January 2015 comprehensive exam, there will be 130 questions, enabling you to earn 26 credits upon successful completion
of the test (or up to 52 credits if also taking the July 2015 exam). $49/exam.
▶ Free Individual Exams – Free to active subscribers of The Medical Letter. Answer 10 questions per issue and submit answers online. Earn two credits/exam.
▶ Paid Individual Exams – Available to non-subscribers. Answer 10 questions per issue and submit answers online. Earn two credits/exam. $12/exam.

ACCREDITATION INFORMATION:
ACCME: The Medical Letter is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Medical
Letter designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity. This CME activity was planned and produced in accordance with the ACCME Essentials and Policies.
AAFP : This enduring material activity, The Medical Letter Continuing Medical Education Program, has been reviewed and is acceptable for up to 52 Prescribed credits by the
American Academy of Family Physicians. Term of approval begins January 1, 2015. Term of approval is for one year from this date. Each issue is approved for 2 Prescribed
credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the
activity.
ACPE: The Medical Letter is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This exam is acceptable
for 2.0 hour(s) of knowledge-based continuing education credit (0.2 CEU).
The American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA) accept AMA Category 1 credit for the Physician’s
Recognition Award from organizations accredited by the ACCME.
This activity, being ACCME (AMA) approved, is acceptable for Category 2-B credit by the American Osteopathic Association (AOA).
Physician Assistants: The National Commission on Certification of Physician Assistants (NCCPA) accepts AMA PRA Category 1 Credit(s)™ from organizations accredited by
ACCME. NCCPA also accepts AAFP Prescribed credits for recertification. The Medical Letter is accredited by both ACCME and AAFP.
Physicians in Canada: Members of The College of Family Physicians of Canada are eligible to receive Mainpro-M1 credits (equivalent to AAFP Prescribed credits) as per our
reciprocal agreement with the American Academy of Family Physicians.
MISSION:
The mission of The Medical Letter’s Continuing Medical Education Program is to support the professional development of healthcare providers including physicians, nurse
practitioners, pharmacists, and physician assistants by providing independent, unbiased drug information and prescribing recommendations that are free of industry influence.
The program content includes current information and unbiased reviews of FDA-approved and off-label uses of drugs, their mechanisms of action, clinical trials, dosage and
administration, adverse effects, and drug interactions. The Medical Letter delivers educational content in the form of self-study material.
The expected outcome of the CME program is to increase the participant’s ability to know, or apply knowledge into practice after assimilating, information presented in
materials contained in The Medical Letter.

The Medical Letter will strive to continually improve the CME program through periodic assessment of the program and activities. The Medical Letter aims to be a leader in
supporting the professional development of healthcare providers through Core Competencies by providing continuing medical education that is unbiased and free of industry
influence. The Medical Letter is supported solely by subscription fees and accepts no advertising, grants, or donations.
GOAL:
Through this program, The Medical Letter expects to provide the healthcare community with unbiased, reliable, and timely educational content that they will use to make
independent and informed therapeutic choices in their practice.
LEARNING OBJECTIVES:
Activity participants will read and assimilate unbiased reviews of FDA-approved and off-label uses of drugs and other treatment modalities. Activity participants will be
able to select and prescribe, or confirm the appropriateness of the prescribed usage of, the drugs and other therapeutic modalities discussed in The Medical Letter with
specific attention to clinical trials, pathophysiology, dosage and administration, drug metabolism and interactions, and patient management. Activity participants will make
independent and informed therapeutic choices in their practice.
Upon completion of this program, the participant will be able to:
1.
Explain the current approach to the management of an overweight or obese patient.
2.
Discuss the pharmacologic and non-pharmacologic options available for an overweight or obese patient and compare them based on their efficacy, dosage and
administration, and potential adverse effects.
3.
Determine the most appropriate therapy given the clinical presentation of an individual patient.
Privacy and Confidentiality: The Medical Letter guarantees our firm commitment to your privacy. We do not sell any of your information. Secure server software (SSL) is used
for commerce transactions through VeriSign, Inc. No credit card information is stored.
IT Requirements: Windows XP/Vista/7/8, Mac OS X+; current versions of Microsoft IE, Mozilla Firefox, Google Chrome, Safari, or any other compatible web browser. Highspeed connection.
Have any questions? Call us at 800-211-2769 or 914-235-0500 or e-mail us at:

Questions start on next page


The Medical Letter

®

Online Continuing Medical Education
DO NOT FAX OR MAIL THIS EXAM
To take CME exams and earn credit, go to:

medicalletter.org/CMEstatus

Issue 1462 Questions

(Correspond to questions #31-40 in Comprehensive Exam #72, available July 2015)
1. Patients are considered obese if they have a BMI of:
a. ≥20
b. ≥25
c. ≥30
d. none of the above
2. Adults can lose 1-2 lb. per week by consuming how many fewer
calories per day?
a. 200-400
b. 300-600
c. 500-1000
d. 600-1200
3. A 24-year-old woman with a BMI of 42 comes to you for advice
on how to lose weight. She asks whether a diet that contains
25% protein would be better for her than one that contains 15%
protein. You could tell her that:
a. either diet would be equally effective in achieving weight
loss
b. there would be no difference between the two diets in the
location of fat mass lost
c. the higher protein diet might be more effective in helping

her reduce weight regain after weight has been lost
d. all of the above
4. Intensive lifestyle intervention in overweight or obese patients
with type 2 diabetes was effective in:
a. achieving and maintaining significant weight loss
b. lowering HbA1c
c. lowering blood pressure
d. all of the above
5. The most effective weight loss drug available to date is:
a. phentermine/topiramate ER
b. orlistat
c. lorcaserin
d. bupropion/naltrexone

6. The major reason for discontinuation of bupropion/naltrexone
has been:
a. constipation
b. nausea
c. rash
d. tinnitus
7. The GLP-1 agonist liraglutide:
a. has not been shown to be effective for weight loss
b. can increase the rate of absorption of other drugs
c. is given by injection
d. all of the above
8. A 36-year-old woman with a BMI of 33 and no history of
diabetes, hypertension, or other obesity-related comorbidities
tells you that she has been trying to lose weight ever since she
was a teenager, but has never been successful in doing so. She
asks your opinion about the advisability of bariatric surgery.

You could tell her that:
a. her BMI and long history of futility in losing weight make
her a good candidate for bariatric surgery
b. all bariatric surgical procedures carry a significant risk of
perioperative mortality
c. she should get the procedure done now before she
develops diabetes or hypertension
d. surgical treatment for obesity is generally limited to
patients with a BMI >40 or a BMI >35 with an obesityrelated comorbidity
9. Both adjustable gastric banding and sleeve gastrectomy:
a. involve a partial gastrectomy
b. are restrictive procedures
c. cause malabsorption
d. all of the above
10. Bariatric surgery has been associated with:
a. remission from diabetes
b. reductions in cardiovascular mortality
c. reductions in all-cause mortality
d. all of the above

ACPE UPN: Per Issue Exam: 0379-0000-15-462-H01-P; Release: February 16, 2015, Expire: February 16, 2016
Comprehensive Exam 72: 0379-0000-15-072-H01-P; Release: July 2015, Expire: July 2016

EDITOR IN CHIEF: Mark Abramowicz, M.D.; EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical School; EDITOR: Jean-Marie Pflomm, Pharm.D.;
ASSISTANT EDITORS, DRUG INFORMATION: Susan M. Daron, Pharm.D., Corinne Z. Morrison, Pharm.D., Michael P. Viscusi, Pharm.D.; CONSULTING EDITORS: Brinda M. Shah, Pharm.D.,
F. Peter Swanson, M.D; SENIOR ASSOCIATE EDITOR: Amy Faucard
CONTRIBUTING EDITORS: Carl W. Bazil, M.D., Ph.D., Columbia University College of Physicians and Surgeons; Vanessa K. Dalton, M.D., M.P.H., University of Michigan Medical
School; Eric J. Epstein, M.D., Albert Einstein College of Medicine; Jane P. Gagliardi, M.D., M.H.S., F.A.C.P., Duke University School of Medicine; Jules Hirsch, M.D., Rockefeller
University; David N. Juurlink, BPhm, M.D., Ph.D., Sunnybrook Health Sciences Centre; Richard B. Kim, M.D., University of Western Ontario; Hans Meinertz, M.D., University Hospital,
Copenhagen; Sandip K. Mukherjee, M.D., F.A.C.C., Yale School of Medicine; Dan M. Roden, M.D., Vanderbilt University School of Medicine; Esperance A.K. Schaefer, M.D., M.P.H.,

Harvard Medical School; F. Estelle R. Simons, M.D., University of Manitoba; Neal H. Steigbigel, M.D., New York University School of Medicine; Arthur M. F. Yee, M.D., Ph.D., F.A.C.R.,
Weill Medical College of Cornell University
MANAGING EDITOR: Susie Wong; ASSISTANT MANAGING EDITOR: Liz Donohue; EDITORIAL ASSISTANT: Cheryl Brown
EXECUTIVE DIRECTOR OF SALES: Gene Carbona; FULFILLMENT & SYSTEMS MANAGER: Cristine Romatowski; DIRECTOR OF MARKETING COMMUNICATIONS: Joanne F. Valentino;
VICE PRESIDENT AND PUBLISHER: Yosef Wissner-Levy
Founded in 1959 by
Arthur Kallet and Harold Aaron, M.D.
Copyright and Disclaimer: The Medical Letter, Inc. is an independent nonprofit organization that provides healthcare professionals with unbiased drug prescribing recommendations. The editorial
process used for its publications relies on a review of published and unpublished literature, with an emphasis on controlled clinical trials, and on the opinions of its consultants. The Medical Letter,
Inc. is supported solely by subscription fees and accepts no advertising, grants, or donations. No part of the material may be reproduced or transmitted by any process in whole or in part without
prior permission in writing. The editors do not warrant that all the material in this publication is accurate and complete in every respect. The editors shall not be held responsible for any damage
resulting from any error, inaccuracy, or omission.

Subscription Services
Address:
The Medical Letter, Inc.
145 Huguenot St. Ste. 312
New Rochelle, NY 10801-7537
www.medicalletter.org

Customer Service:
Call: 800-211-2769 or 914-235-0500
Fax: 914-632-1733
E-mail:

Permissions:
To reproduce any portion of this issue,
please e-mail your request to:

Copyright 2015. ISSN 1523-2859

Subscriptions (US):
1 year - $98; 2 years - $189;
3 years - $279. $49 per year
for students, interns, residents, and
fellows in the US and Canada.
Reprints - $12 each.

Site License Inquiries:
E-mail:
Call: 800-211-2769 ext. 315
Special rates available for bulk
subscriptions.